The purpose of this article is to present the Balance Evaluation Systems Test (BESTest) and its use in the clinical setting.
Learning objectives
Understand the purpose of the BESTest
Develop a basic understanding of the six systems the test is designed to measure
Understand the advantages and disadvantages of using the test
Understand how to clinically apply the test
History of the Test
The Balance Evaluation Systems Test (BESTest) was created by Fay B Horak, Ph.D, PT, a professor of neurology and biomechanical engineering at Oregon Health and Science University (Hoark, Wrisley, & Frank, 2009).
Test Purpose
The BESTest is a systems approach to balance testing using 36 items grouped into six systems. It has been adopted as a tool for any age and severity—including:
Parkinson’s disease (Duncan et al., 2013)
Cerebellar disorders
Vestibular disorders
Neuropathy
Multiple sclerosis (Jacobs and Kasser, 2012)
Knee OA (Tamura et al., 2016)
Cerebral palsy
COPD (Jacome et al., 2016)
Stroke (Chinsongkram et al., 2014)
Other balance disorders
What does it measure?
The BESTest differentiates balance into six systems:
Biomechanical constraints
Stability limits/verticality
Anticipatory postural adjustments
Reactive postural responses
Sensory orientation
Stability in gait
Scoring
A total score of 108 points can be reached from totaling each four-point scale. The final, overall score, is calculated as a percentage. Scores range from zero (worst performance) to 3 (best performance). Horak et al (2009) reported a minimal detectable change of 8.9.
Comprehensive test that identifies underlying postural deficits
Helps guide interventions based on which system is compromised
It has good interrater reliability with an ICC = 0.91 (Hoark, Wrisley, & Frank, 2009)
It has good interrater reliability with an ICC=.99 (Chinsongkram et al, 2014)
Disadvantages
Timely to administer (takes about 20-30 minutes)
Requires several assessment tools
Doesn’t measure fear of falling (i.e, balance confidence)
Doesn’t measure vertical head turns
Only contains one cognitive constraint (i.e., TUG plus dual tasking)
No minimally clinically important difference (MCID) has been established
Overview of Test
The BESTest looks at the interaction of several systems and is one of the most comprehensive balance tools available (Hoark, Wrisley, & Frank, 2009).
Biomechanical Constraints – Section I looks at constraints that can affect the biomechanics of the body, such as limits of stability, ankle/hip strength, ankle/hip ROM, and postural alignment.
Stability Limits – Section II addresses movement over the patient’s base of support or how far the body’s center of mass can be moved over its base of support. It also looks at verticality.
Anticipatory Postural Adjustments – Section III looks at how a subject’s feedforward postural balance reaction to voluntary, transitional movements.
Reactive Postural Responses – Section IV tests compensatory stepping and recovery strategies in different directions. This section helps the practitioner look at ankle, hip, and stepping strategies.
Sensory Orientation – Section V looks at spatial orientation involving vestibular, vision and sensory pathways.
Stability in Gait – The final section tests constraints on dynamic balance, gait speed and negotiation over obstacles. There is also a cognitive component with dual tasking combined with the TUG.
Suggestions
Think of the BESTest as a guide for goal setting and intervention development
If you are short on time, use individual sections of the BESTest for a specific postural system.
Use the shortened mini-BESTest, which is just as reliable and valid as the BESTest (Jacome et al., 2016)
Use the BESTest a test for frailty and to prevent falls for older community ambulating adults
If you specifically need to look at the fear of falling, The Activities-Specific Balance Confidence Scale (ABC) could be used in conjunction with the BESTest.
Berg KO, Wood-Dauphinée S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995;27:27–36.
Chinsongkram, B., Chaikeeree, N., et. al. (2014). Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke. Physical Therapy 94(11), 1632-1643.
Duncan, RP et al. Comparative utility of the BESTest, mini-BESTest, and brief-BESTest for predicting falls in individuals with Parkinson disease: a cohort study. Phys Ther. 2013 Apr;93(4):542-50. doi: 10.2522/ptj.20120302. Epub 2012 Nov 21.
Jacobs, JV. & Kasser, SL, (2012). Balance impairment in people with multiple sclerosis: Preliminary evidence for the Balance Evaluation Systems Test. Gait & Posture 36: 414-418.
Jácome, C, Cruz, J, Oliveira, A, Marques, A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Phys Ther. 2016 Apr 14.
Tamura, T, Otaka, Y, Konno, S, Sadashima, K1 Tomatsu, T, & Machida, S. The Impaired Balance Systems Identified by the BESTest in Older Patients With Knee Osteoarthritis. PM R. 2016 Feb 16. pii: S1934-1482(16)00072-1. doi: 10.1016/j.pmrj.2016.02.002. [Epub ahead of print]
Learning objectives
History of the Test
The Balance Evaluation Systems Test (BESTest) was created by Fay B Horak, Ph.D, PT, a professor of neurology and biomechanical engineering at Oregon Health and Science University (Hoark, Wrisley, & Frank, 2009).
Test Purpose
The BESTest is a systems approach to balance testing using 36 items grouped into six systems. It has been adopted as a tool for any age and severity—including:
What does it measure?
The BESTest differentiates balance into six systems:
Scoring
A total score of 108 points can be reached from totaling each four-point scale. The final, overall score, is calculated as a percentage. Scores range from zero (worst performance) to 3 (best performance). Horak et al (2009) reported a minimal detectable change of 8.9.
Tools Required
Stop watch, measuring tape, 10-degree incline ramp, medium-density foam, stair step, two stacked shoe boxes, 5 lb weight, chair, and masking tape.
Advantages
Disadvantages
Overview of Test
The BESTest looks at the interaction of several systems and is one of the most comprehensive balance tools available (Hoark, Wrisley, & Frank, 2009).
Suggestions
Additional Resources
BESTest site: http://www.bestest.us
Link to Mini-BESTest http://www.bestest.us/test_copies
Rehab Measures information http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1040
Neurology Section of APTA http://www.neuropt.org
Exercise Programs for people with disabilities and injuries https://www.physiotherapyexercises.com/
References
Berg KO, Wood-Dauphinée S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995;27:27–36.
Chinsongkram, B et al. Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke. Phys Ther. 2014 Nov;94(11):1632-43. doi: 10.2522/ptj.20130558. Epub 2014 Jun 12.
Chinsongkram, B., Chaikeeree, N., et. al. (2014). Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke. Physical Therapy 94(11), 1632-1643.
Duncan, RP et al. Comparative utility of the BESTest, mini-BESTest, and brief-BESTest for predicting falls in individuals with Parkinson disease: a cohort study. Phys Ther. 2013 Apr;93(4):542-50. doi: 10.2522/ptj.20120302. Epub 2012 Nov 21.
Horak, F. B., Wrisley, D. M., & Frank, J. (2009). The Balance Evaluation Systems Test (BESTest) to Differentiate Balance Deficits. Physical Therapy,89(5), 484–498. http://doi.org.courseinfo.wssu.edu:2048/10.2522/ptj.20080071
Jacobs, JV. & Kasser, SL, (2012). Balance impairment in people with multiple sclerosis: Preliminary evidence for the Balance Evaluation Systems Test. Gait & Posture 36: 414-418.
Jácome, C, Cruz, J, Oliveira, A, Marques, A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Phys Ther. 2016 Apr 14.
Tamura, T, Otaka, Y, Konno, S, Sadashima, K1 Tomatsu, T, & Machida, S. The Impaired Balance Systems Identified by the BESTest in Older Patients With Knee Osteoarthritis. PM R. 2016 Feb 16. pii: S1934-1482(16)00072-1. doi: 10.1016/j.pmrj.2016.02.002. [Epub ahead of print]